Knowledge/Thoughts on Documentation So Far by Stephanie Lancaster

2024-11-04 17:30:49 UTC

It needs to be thorough!

Descriptive

2024-11-04 17:30:57 UTC

2024-11-04 17:31:01 UTC

important for legal/insurance reasons

2024-11-04 17:31:01 UTC

Different across settings!

2024-11-04 17:31:03 UTC

It needs to be short to the point

SOAP note format, short term goals, long term goals,

2024-11-04 17:31:04 UTC

2024-11-04 17:31:05 UTC

time consuming...

SOAP!

2024-11-04 17:31:05 UTC

2024-11-04 17:31:09 UTC

S.O.A.P.

2024-11-04 17:31:13 UTC

It is different for every setting

2024-11-04 17:31:13 UTC

another therapist should be able to read it and pick up where you left off

2024-11-04 17:31:14 UTC

Can be time-consuming

Precise

2024-11-04 17:31:16 UTC

Maintain HIPPA standards

2024-11-04 17:31:19 UTC

2024-11-04 17:31:21 UTC

detailed orientated from observations but written concisely

how we get paid!

2024-11-04 17:31:24 UTC

time frame is included

2024-11-04 17:31:26 UTC

2024-11-04 17:31:27 UTC

Many different forms of documentation

Client Progress

2024-11-04 17:31:29 UTC

2024-11-04 17:31:33 UTC

Use accurate, appropriate OT lingo and medical terminology

2024-11-04 17:31:33 UTC

starts as soon as we enter the patients room

OT Lingo

2024-11-04 17:31:33 UTC

Everything you did to protect you in the long run

2024-11-04 17:31:34 UTC

documentation = reimbursement for services

informative

2024-11-04 17:31:34 UTC

Documentation in OT

2024-11-04 17:31:45 UTC

Documentation is the on paper source for other professional personnel to look over. Putting thoughts on paper

SOAP

2024-11-04 17:31:48 UTC

detailed, professional terminology

2024-11-04 17:31:51 UTC

May feel redundant.

2024-11-04 17:31:53 UTC

Documentation

2024-11-04 17:31:54 UTC

It needs to be short and sweet and provide great details.

Documentation can be long but needs to be correct

2024-11-04 17:31:59 UTC

Takes time

2024-11-04 17:32:02 UTC

2024-11-04 17:32:12 UTC

Time consuming

different settings have different time frames it has to be turned in

2024-11-04 17:32:13 UTC

should be concise; NO ESSAYS

2024-11-04 17:32:17 UTC

2024-11-04 17:32:18 UTC

Documentation needs to have accurate information for insurance companies to understand what you are doing in practice. It needs to be thorough, however some documentation varies across settings especially hand therapy compared to pediatric settings.

2024-11-04 17:32:25 UTC

different clinics have different sites/companies they use

2024-11-04 17:32:27 UTC

Covers your bases

2024-11-04 17:32:44 UTC

The note need to be thorough so that all other health professionals know what’s going on with the client.

Correct spelling of clients name, etc or will be rejected by insurance company

2024-11-04 17:33:43 UTC

2024-11-04 17:34:21 UTC

your analysis

2024-11-04 17:34:38 UTC

Important for others to be able to go back and see what happened last, if its not the same therapist